The University of Utah Community Clinics (CC) are a network of 10 multidisciplinary university-owned primary care practices with diverse patient populations, settings, and organizational cultures. The CC began implementing in 2003 our version of PCMH, which we call Care by Design (CBD). CBD is organized around the principles of Appropriate Access, Care Teams, and Planned Care, all supported by a robust electronic medical record (EMR) that has been in place since the start of the transformation. We propose to use a combination of quantitative and qualitative methods to document how we accomplished the transformation, and to identify its clinical and operational outcomes. For the quantitative analyses, we will use a measurement tool we have developed to assess the degree to which clinics implemented the essential components of CBD. We will analyze trend data for a large set of clinical quality measures related to diabetes, coronary heart disease, heart failure, asthma and preventive care. We will analyze correlations between extent of implementation of CBD at each clinic with operational measures such as costs for staff and providers, facilities, and supplies. We will identify relationships between CBD implementation and satisfaction of providers, staff, and patients. We will examine total cost of care at the patient level using the newly-available Utah All Payer Database (APD) for those under age 65 years, and using Medicare data for those over age 65. We will also analyze the change process itself using retrospective qualitative methods. Through oral histories obtained from the leadership and clinical team members who developed and implemented CBD, we will document the management practices used during the implementation and assess the experience of change through the eyes of these key informants. We will gain a broader sense of the experience of transformation by surveying other providers and staff about organizational culture, the team environment, and potential staff burnout. We will explore patients'experiences through focus group interviews and through administration of the CAHPS Clinician &Group Survey supplemented with items to assess the patients'experience of patient- centeredness and value they perceive from the transformation. PUBLIC HEALTH RELEVANCE: The Patient-Centered Medical Home (PCMH) model is expected to help achieve the triple aims of access, quality, and cost effectiveness. The University of Utah Community Clinics have transformed practice of primary care by implementing our version of PCMH, known as "Care by Design" (CBD). We will use multiple quantitative and qualitative methods to identify critical success factors for the transformation process, and to measure outcomes of transformation. Our experience holds valuable lessons for other practices seeking to change